DISTRICT HEALTH AND FAMILY WELFARE SOCIETY, JIND

APPLICATION FORM

For office use

Receipt No.----------------------- dated-------------------

Important Instructions
 Please read instruction given in advertisement carefully before filling in each column.
 Use only black/blue ball pen to fill the form. Please fill the form in capital letter.
Application for the post :-

Sr. No. _______ Name of Post____________________________________ Category____________

1. Name of the candidate :

( In Capital letter)
2. Father’s Husband Name : Affix Recent
( In Capital letter) Colored
3. Husband Name : Passport Size
( In Capital letter) Photo
4. Sex :
5. Date of Birth : _
(DD/MM/YYYY)
6. Category to which belong : Caste

7. Telephone / Mobile No. :

8. E-mail :

9. Permanent Address :

PIN CODE

10. Correspondence Address :

PIN CODE

11. Educational / Professional Qualifications :

Examination Board/ Year of Maximum Marks %age Division Subject

Passed University Passing Marks Obtained of
marks
10th

10+2 /
Vocational /
Intermediate

Graduation
 Post
Graduation

Any other
Course /
Diploma etc

12. Internship / Training (if any): Year(s) Month(s) Day(s)

Name of Institution / Designation From To Total period

Organization

13. Total Experience: Year(s) Month(s) Day(s)

Name of Institution / Designation From To Pay/Salary / Total

Organization Honorarium period
p.m.

14. Detail of document attached:-

1.-------------------------- 2.-------------------------- 3.------------------------ 4.------------------------------

5.---------------------------- 6.-------------------------- 7.-------------------------8.------------------------------
9.--------------------------- 10.-------------------------

15. Declaration : I hereby declare that

1. All statements made in this application form are true, complete and correct to the best of my knowledge and belief. In the event
of any information being found false or incorrect, or ineligibility being detected before or after the
interview/selection/appointment, my candidature may be cancelled and action can be taken against me by the department.
2. I have read the provisions in advertisement of the omission carefully and I hereby undertake to abide by them. I fulfill all the
conditions of eligibility regarding age limits, educational qualifications etc. prescribed in the advertisement and other relevant
rules and instructions.
3. I have never been convicted by criminal court.
4. There is no court case pending against me.

Date :
Place : Signatures of the Candidate